How cognitive appraisal might impact a child with mood regulation problems is depicted by Owen, a 4-year-old child who was struggling at preschool. He often became irritable when there were transitions in activities, his space was invaded by other children, activities were more rambunctious, or when the classroom noise level became loud. He felt that he wasn’t ready to move on to the next activity when the children were expected to do so. Although he was a very competent child, he had trouble adjusting to change and would become distressed when expected to do certain tasks, such as share toys with other children or clean up his toys to get ready for snack. Usually after about 2 hours at school, Owen would begin to show his distress by hitting or biting other children or by withdrawing. His responses were very unpredictable with some good days, then followed by several days with multiple incidents. Each time he bit a child, he was sent home from school. Within a month, he was being sent home so frequently that his parents chose to keep him at home to give him a break from the stress of school. As we tried to work out a viable solution to the problem (e.g., getting a full-time aide to help him make transitions, to stop him before he bit another child, and to organize him when he appeared distressed), Owen began to make comments that he never wanted to go back to school again. In the next month that it took to find an aide, we saw Owen regress. With each day that he stayed home from school, he became increasingly more agitated, refusing to change his clothes, wanting to isolate himself in his bedroom, and screaming at his parents whenever they made the simplest of requests. As we reintroduced Owen back into school, we had to change his cognitive appraisal of school and himself to a more positive one. We were able to accomplish this by beginning with a short school day and a shortened week of school at first and using positive reinforcement from his aide for accomplishing tasks. We provided scheduled breaks during the day when he could reorganize himself (e.g., calming by sitting in a bean bag chair and looking at books, sucking on ice pops, or building a fort that he could go inside). We instituted a school and home program that reinforced good behavior and compliance, for playing friendly (e.g., not biting other children), making transitions (e.g., clean up toys when time for snack), and self-calming when agitated (e.g., asking for time alone in bean bag chair). Within a few months he became much more compliant both at home and school and was beginning to make more positive self-statements (e.g., “I want to go to school”; “I like doing this” instead of “I’m a bad boy,” “I’m angry”) and playing more with other children in a prosocial way.

The young child is more dependent upon facial cues of individuals experiencing the event, but as children grow older through the school-aged years, they rely more on situational cues. As children mature, they are also better able to integrate both facial and situational cues (Hoffner & Badzinski, 1989). We see this in many everyday situations with adults as well. Suppose you are invited to attend a social gathering of persons from a highly different socioeconomic and cultural background. Most individuals would watch others who are comfortable with the situation to determine what behaviors are expected. Men and women may talk together in segregated groups. It may be expected that jokes will be received with modest chuckling versus loud laughing. The hostess may be offended if the guests do not eat second and third helpings of food.

In contrast, Cannon (1927) argued that autonomic changes occurred in response to brain processes which defined the experience of emotion. A person would first assess a situation as one evoking fear, then would experience the associated autonomic responses.

The question posed by these two theorists is an interesting one. How would a lack of afferent feedback influence the ability to experience emotions? Imagine the patient with an artificial heart who would not experience shifts in heart rate during different emotional experiences. Would this individual feel emotions in the same way as previously experienced before heart surgery?

But what happens when a person assumes a facial expression by simply contracting different facial muscles that are part of that particular expression? Do they experience the emotion as well? Here is an experiment for you to try. Raise your brows, hold them raised, and pull your brows together, now raise your upper eyelid and tighten the lower eyelid, and stretch your lips horizontally. What does your face look like? Your face should look as if you are experiencing fear. Did you feel any autonomic changes that were related to fear?

In an experiment where subjects assumed different facial expressions in the same way that you just did, the subjects experienced different autonomic changes, such as changes in skin temperature and heart rate (Ekman et al., 1983). Of course, the autonomic changes are mild in contrast to when the emotion is actually experienced. These results may explain why some people who are feeling low can pick up their mood by “putting on a happy face.” The act of smiling may actually elevate the way we feel even if it starts out as deliberate rather than spontaneous.

In the second stage, the spinal sympathetic nervous system is activated which serves in increasing metabolic output while inhibiting primitive vagal influences. This stage is one of mobilization and is represented in the person’s capacity to engage in “fight or flight” when confronted with threatening stimuli.

The third stage is characterized by the myelinated vagal system that helps to regulate cardiac output and to foster engagement and disengagement with the environment. It is brain stem mediated and it controls facial expression, sucking and swallowing, breathing, and vocalization. This system has an inhibitory effect on the sympathetic nervous system, effects on cardiac function, and promotes physiological calming. Porges (1995) theorizes that this is the system that provides the neurological basis for early mother–infant interactions, as well as the development of complex social behaviors. Some of the social behaviors that this system impacts are emotional expression, vocal communication, and contingent social behaviors.

In treatment we frequently use deep breathing exercises to help calm states of agitation, anger, or other dysregulated mood states. The polyvagal theory helps to explain the neural mechanism behind why deep breathing helps calm the nervous system to allow for better social engagement and attachment to others.

Developmental shifts are observed in neurophysiological control of facial expressivity. With maturation, the infant displays a greater range of expressivity but, at the same time, can self-regulate affect in response to situational demands, thereby showing a trend toward greater cortical control of facial expressions. There is also greater control of autonomic functions with age. As the individual matures, they are less likely to respond with high variability in autonomic responses (i.e., heart rate and respiration) as they learn to adapt to various novel or stressful situations. Therefore, in normal development, there is greater myelinization of the brain in conjunction with greater regulation of autonomic functions that parallels the affective expressivity and control.

Some individuals seem to have a great deal of difficulty in recognizing the autonomic responses that accompany emotions. As a result, they may not perceive that they are getting angry or upset until they suddenly blow up. This has important implications for parents who may be at risk for abusing their children. It is important to teach them how to recognize the bodily signals that mean they are getting angry (e.g., stiffening of muscles, skin getting hot, stomach churning, and so on) so that they can cool off before they explode at their child. By tuning into these body signals, the person can learn to control their behavior better.

The task of learning how to read body signals was a major piece of intervention with 9-year-old Alexis. She had a short fuse and would explode, screaming at her parents and throwing things whenever she experienced the slightest bit of frustration. Her tantrums would go on for several hours which resulted in the whole family being up to all hours of the night trying to console her. Her parents thought that Alexis looked like a wild animal with hair falling in her face, her body slumped over, and hands clawing at the air like a tiger. Alexis would also shut down when she became depressed, hiding under a table or sitting inside her closet for hours on end. These mood changes would come on suddenly and once in an intense mood state, Alexis had considerable difficulty coming out of them. Although she was a child who was helped by medications, through therapy Alexis began to be able to recognize when she could feel her mood shifting to anger, frustration, or sadness. When she felt herself becoming upset by things, she could focus on what her body was telling her, then take steps to soothe herself before her mood state progressed too far. Doing things like jumping on a trampoline, kicking a soccer ball, or playing piano helped her to self-calm. Alexis also talked with me about her “Tantrum Warning Device,” (a rainbow colored semicircle ranging from red for anger, orange for agitated, yellow for frustrated, green for calm, and blue for sad) a concept that we used to help her predict what situations caused her to become upset. For instance, doing homework almost always caused her warning meter to go up to a “medium sizzle.” Not getting to stay up late and play Nintendo would make her get “boiling mad.” The object of the warning device was to recognize when her mood was moving from mild to mild-medium or medium anger and get it back down again by calming herself.

Baby cries are heard in the first few minutes of life, however, different types of cries and cry expressions related to different negative affects (sorrow, fear, anger, pain) develop as the child matures. This differentiation in emotional expression occurs for all emotions and relates to the individual learning to attach different meanings to events.

A number of studies have reported that the left side of the face dominates affective expression—that is, the left side of the face shows greater facial movement and is more intense than the right side during spontaneous emotion. Most investigators have attributed this to right hemispheric lateralization for emotion (Fox & Davidson, 1984).

Both hemispheres contribute differentially to the experience and expression of positive and negative emotions. States of positive emotion are associated with left frontal activation while states of negative emotion are associated with right frontal activation (Davidson, 1984). The left hemisphere also plays an important role in the inhibition of negative affects by suppressing right hemispheric activity. This inhibition begins when children develop verbal fluency, around 18 months of age.

The emergence of different emotions also follows a developmental progression that relates to neural maturation. The emotions of interest and disgust appear to be under unilateral hemispheric control and are present in the newborn at a time when there is little functional interconnection between the hemispheres. Fear and sadness usually do not emerge until the end of the first year when interhemispheric communication is developing. However, a child who has been maltreated by caregivers, or hospitalized for a serious illness, or whose caregiver is seriously depressed may suffer from an anaclitic depression in the first year of life. The onset of locomotion, a behavior associated with commissural communication, also occurs with the emergence of fear. The baby is not only able to experience fear but can escape fear-provoking events with efficiency. Expression of sadness usually develops in the second year of life and is associated with alternation between approach and withdrawal, thus implicating interhemispheric communication (Fox & Davidson, 1984).

Feedback from the body may serve to help regulate affect. Certain body postures give more feedback than others. For example, a “sad” body posture with collapse into flexion causes the least firing of proprioceptors in the neck and trunk. A “happy” posture causes a high degree of proprioceptive discharge from the extensors. It is used therapeutically when we use muscle relaxation techniques on the highly anxious or hyperaroused individual. Through a change in body posture, the goal is to help the person to unblock negative emotions or to alter arousal for more focused purposeful attentive behavior.

Children with sensory integrative dysfunction, especially problems related to muscle tone and motor planning, are likely to have difficulty in modulating affective expression because their bodies do not provide accurate feedback related to postures that accompany facial expressions. Sometimes there are major implications for the child. The following case example depicts how these problems might play out.

Patricia was a very bright 6-year-old child with severe motor planning problems. She appeared happy and content, but experienced enormous frustration that she was so accident prone and slow to learn things that should be automatic (e.g., riding a bicycle). She was just beginning to dress herself and was still struggling with tasks like tying her shoelaces and buttoning her clothes. Patricia had developed high anxiety, behavioral resistance, and learned helplessness related to any task that required motor planning. For example, Patricia was afraid of heights that affected her ability to climb stairs. When she would climb a flight of stairs at home, school, or other places, such as a museum, she would become overwhelmed with fear. Instead of using her words to say she was afraid, she would cling to her mother or father and say she had to go home right away, saying that she was going to vomit. She did, in fact, sometimes become motion sick in the car and would experience autonomic reactions to movement (e.g., feeling like she would vomit after swinging on a swing). Patricia did not like to take any risks and appeared to derive satisfaction from activities when she was involved vicariously. For example, she would command her parents to dress her dolls in certain outfits, changing their clothes several times in a row, then she would want them to set up her doll house in a particular way, often changing her mind and wanting them to set it up all over again. If they did something different than she wanted, she would yell at them loudly and begin to throw tantrums. Patricia was a child who often assumed a watchful role in her life activities, but when she engaged with others, she would often become intense and verbally aggressive. It seemed that the lack of adequate sensory feedback that she experienced from her body coupled with severe motor planning problems contributed to her strong sense of inadequacy and inability to modulate affect. She seemed to function at two ends of the spectrum—either passive and submissive or screaming and intense. Becoming more attuned to feedback from her own body while working on appropriate ways to control others and the environment were emphasized in her therapy program.

Another important way that we regulate emotions are in relation to our own internal goals. They help us to evaluate our success in accomplishing our goals and motivate our activity in further pursuit of our goals. Internal goals may be immediate in nature and relate to security and basic homeostasis. For example, a high-risk family may be faced with putting food on the table and finding shelter. Another internal goal may be sharing interactions with others. For example, the young child may bring a toy to his father hoping that he will play a game with him. We also have internal goals for mastery and accomplishment of skill. While learning a new skill, a person may experience frustration and anger. Picture the person learning to play golf who continually misses the ball and hits the ball into the woods and sand traps. On the other hand, a person may feel a positive emotional state while learning a new skill—such as joy and interest—which further motivates engagement in the activity. Take the young child who is learning how to crawl or walk and practices this skill over and over again. But if there is a block or an obstacle in the way that is too difficult to overcome, such as a gate blocking entry to the stairs, the infant may become distressed and angry. After a while, if the infant cannot overcome the obstacle or an adult does not respond to the baby’s expression of distress, the infant may feel defeated, sad, and eventually withdraw from the situation.

Field (1977,  1980) has proposed an “optimal stimulation” model of affect and interaction. If the mother provides too much or too little stimulation, the infant withdraws from the interaction. The optimal level varies considerably from one infant to the next and depends upon the infant’s threshold for arousal, tolerance for stimulation, and ability to self-control arousal. If the mother maintains the infant at an optimal level, an interchange of smiling and gazing occurs. An increase in the infant’s attentiveness may relate to the mother becoming less active and more attentive to the infant’s gaze or when the mother engages in imitations of her infant’s behaviors. When the mother becomes more active, the infant tends to be less attentive. Adults also seek to modulate their arousal during interactions in similar ways. For example, two friends talking in a highly stimulating environment, such as a crowded shopping mall may look away intermittently from the person speaking.

Moods do not have a facial expression. For example, a person who is feeling irritable may become angry very easily and stay angry longer than a person who is not irritable. The irritable mood though does not have a distinct facial signal. When a person has a predominant mood, such as feeling depressed, they will typically show a high frequency of sad expressions (Ekman, 1984).

Moods may be produced in different ways. Changes in biochemical balances, such as diet, disease, fatigue, exertion, or a stimulating sensory experience can produce different mood states. For example, if a person is tired, they may be more irritable. Or a child who rides on a series of carnival rides may become very hyperexcitable and happy. If a particular emotion is elicited repeatedly over the course of a short period of time, it may produce a biochemical change that causes a mood state to prevail. If a person has experienced a series of maladies in a row, they may become angry and irritable over time.

The feelings that are associated with emotions may be anticipatory in nature, such as anticipation of an exciting event (i.e., opening a birthday present). It may also be anticipatory dread or fear (i.e., presenting a speech in front of a large audience or an upcoming piano lesson after not practicing for a few weeks). Feelings also occur while an emotion is being expressed. Oftentimes, we hear people express these verbally while engaged in an activity. For example, we hear children exclaim, “This is fun!” Feelings may be elicited by memories of the event. Certain words, smells, or places often evoke strong feelings of past events. Sometimes children reared in institutional settings, such as an orphanage in Russia remember things from their very early childhood based on certain sensations or smells. For example, 5-year-old Katarina cried and stated, “You’re not going to tie my hands down, are you?” when her parents went to a hotel and showed her a spring mattress that she would be sleeping in. Evidently the spring mattress must have reminded her of her early days in the orphanage when she was restrained in bed.

The capacity for engagement and attachment has to do with both physical capacities of the infant, such as the ability to modulate and process sensory experiences (including visual, auditory, tactile, olfactory, vestibular, proprioceptive), and the ability to coordinate simple motor actions, such as reaching for the caregiver’s face. The infant learns to engage in mutually satisfying experiences with the affective world. For example, the parent may play reciprocal cooing games with his or her baby. As the infant learns to regulate states of arousal, he can focus attention to take interest in the world while also adapting to a variety of sensory stimulations experienced in everyday life (i.e., being held and carried, fed, or bathed). As the caregiver provides soothing and organizing sensory and affective experiences for the baby, the infant forms a special emotional interest with the caregiver.

Problems at this early stage can have wide-reaching implications life-long. For instance, Sylvia was distraught when a favorite aunt offered her 7-year-old child a birthday present, something that delighted her daughter but upset Sylvia very much. She couldn’t seem to explain her emotional reaction, but she felt furious at the aunt for giving a gift to her daughter with such warmth and caring. Sylvia had suffered from emotional deprivation growing up and never experienced being given to and nurtured in pleasurable ways. On a cognitive level, she knew that she should be happy that her daughter was receiving something she didn’t get as a child, but on a visceral level, it made her feel neglected.

An important hallmark of this stage is the development of intentional organized communication to human interactions. We observe the child engaging in interactive signaling with others through gestures, words, and actions. For example, a 9-month-old often enjoys the game of tossing his cup and plate onto the floor while sitting in the high chair. At first it may become a playful game, the infant gesturing toward his cup on the floor and smiling as his father returns it to his tray. But if the dad tires of the game and ignores baby’s wishes to continue the game, the baby begins to clench his fists and look angry, even banging on the lap tray to show his anger. Through these interactive exchanges, the baby begins to organize and communicate emotions, such as assertiveness, curiosity, anger, dependency, and pleasure. By 15–18 months, interactive signaling becomes more organized. The toddler can communicate not only in proximal space, but also in distal space. The toddler may toddle across the room to knock down a large block tower, then look over to see if his mother noticed him. If the mother smiles admiringly and tells him, “What a big boy!” the toddler interprets her words and gestures as encouraging. This distal connection with the mother, also known as social referencing, enables the toddler to continue playing from across the room without having to go back to sit on mom’s lap. He can feel her reassuring presence through her approving nods. He can gesture to her about feelings of frustration or anger when he can’t successfully build the block tower, such as throwing the block and scowling.

During the level of intentional organized patterns, the toddler learns to use complex preverbal gesturing and sounds to engage with his world in a new way. Communications become reciprocal in nature and the toddler learns that he can give and receive information from others through different channels (e.g., gestures and words, as well as sensory and motor experiences, such as rough housing with father). The toddler communicates emotional meanings through these channels. For example, he may challenge the limits of safety by testing whether he can touch an electrical outlet at home or unbuckle his seat belt while riding in the car. He may look for reassurance and acceptance by putting away her book on the shelf. Many of the important life messages are learned during this stage including love and approval versus hate and rejection, safety versus danger, and a respect and empathy for self and others versus impersonal detachment.

Many children with mood dysregulation including those with autism spectrum disorders, ADHD, or those who have suffered abuse, neglect, or trauma often do not develop the capacity for interactive signaling, reciprocity, and the ability to integrate thoughts and feelings for adaptive social behavior. They may lack a sense of self and be unable to differentiate the range of emotions, such as assertion and needs for dependency, self limit setting, or empathy.

During this stage, the child attaches meaning to concrete events. For example, the toddler can label pictures (e.g., “D.W. is happy. She found the ring.”) and describe objects in affective terms (e.g., the scary monster, the favorite stuffed animal). He can also describe his own feeling states (e.g., “I want that,” “my turn”). As the child moves into pretend play, he or she can enact simple to complex dramas that reflect everyday sequences and their meanings to the child, such as feeding the dolls, going to the store, then coming home to sleep. Older children do the same thing through story telling, poetry, or art.

As emotions become differentiated and the child has a stronger sense of himself and others, experience becomes categorized into functionally relevant patterns. As the child can communicate through words and pretend play, wishes and emotions are expressed. The child can shift between fantasy and reality in play (“that’s pretend, isn’t it?”). He also learns to understand his impact on others (i.e., saying sorry when he spills his juice on another child).

The ability to engage can be compromised by several things. There may be difficulties in sensory modulation or processing, such as the baby who is sensitive to touch or high-pitched sounds and who avoids or withdraws from the human world. Difficulties with muscle tone or coordination can affect the infant’s ability to signal interest in the world. For example, the young infant who arches away from the mother’s breast during feeding due to oral hypersensitivities or an imbalance in muscle tone will affect the level of engagement that occurs during feeding. These problems in the infant will affect the caregiver’s ability to respond, particularly when they do not understand what the baby’s responses mean. The mother whose baby arches away when he is held may feel that she is being rejected or that she is not a good mother, particularly if the baby’s tactile hypersensitivities or increased muscle tone are not understood.

Even when the infant is competent from a sensorimotor standpoint, a caregiver might fail to draw a baby into a relationship (e.g., a caregiver who is depressed or who is self-absorbed may not woo their new infant). This can have lifelong implications for the person. For example, Carol’s mother was an alcoholic who was more concerned about her own social life than raising her three children. The father traveled and was rarely home. Carol’s mother frequently abandoned the children to go out to parties and left the house in chaos with no food for the children to eat. As Carol grew up, she observed the horrible disrepair of the household, the stark neglect from her mother, and felt that she was worthless, undeserving, and unlovable. When Carol became a mother, she was constantly getting into battles with her husband, children, and family members, not knowing how to be in a mutually rewarding and reciprocal relationship. She struggled with how to provide a nurturing and stable home environment for her own children which was the focus of our work together.

Physical traits, temperament, ability to self-regulate, sensorimotor capacities, and interactive capacities can have a significant role in the baby’s capacity for engagement. Variations in the capacity for engagement are often a central aspect that underlies different types of psychopathology in later childhood and adulthood. Difficulties that are encountered at the level of engagement, may be evidenced by a lack of relatedness to the human world. For example, the child may appear aloof or distant, “beating to their own drummer” as Greenspan describes, or they may be autistic-like. One can observe the quality of engagement in terms of its stability and how well it is maintained when challenged by stress or demands. For example, a child may remain engaged in play as long as it is the child’s agenda, but as soon as the adult requires the child to follow a routine, make a transition, or adhere to any other demand, such as cleaning up, the child may become disengaged. For some individuals, the stress that causes them to disengage may be certain types of sensory stimulation (e.g., loud noises, someone touching them in an effort to be close). The qualities of the engagement may also vary depending upon the challenges that confront the child. For example, the child may appear mechanical in their interactions, emotionally labile, or very demanding of attention from others.

Eating healthy at regular times (e.g., 3 meals per day plus two snacks for young children) and avoiding a diet high in carbs, sugar, and fried food is highly beneficial to the child’s physical health. In addition, getting a good night’s sleep and keeping a regular sleep schedule is very important. Without these basics in place, the child is apt to be irritable.

It is important in the therapy to find ways to decrease stimulation at home and school environments, as well as streamlining the number of activities that the child is doing. The mantra is “less is better” and “one thing at a time.” It is very useful to eliminate or scale back on activities that create a state of urgency or rushing around. The therapist should model calmness and practice meditation and relaxation techniques with the child in session (see Skill Sheet #7: Mindfulness: stilling the mind). In addition, the child should find healthy escapes or self-distractions that give them an opportunity to leave a situation that is overwhelming or overstimulating. This is often an educational accommodation for school-aged children when they are issued a pass to take a short break in a quiet room to regroup, practice deep breathing, and calming their mind.

Many preschool and school-aged children respond well to a calm-down area that both provides containment and offers them activities to regroup. Pup tents or a small designated area of the house may work well for this purpose. For example, the parents may place a table cloth over a card table and fill it with pillows or create a space between the back of the sofa and the wall where the child can retreat when overstimulated. In this space, there should be a box of calm-down materials that help the child (e.g., puzzles, books, squeeze balls, or other calming materials). To install the calm-down area, the parents should practice going there with the child at moments when they are calm or dysregulated. Since many children who are irritable fall apart during transitions, the parents may have several calm-down boxes that can be used for different situations (e.g., a box in the glove compartment of the car for car rides).

An important aspect of parent guidance is to help the parents help the child to develop self-calming. Children who are fussy often depend upon others to calm them rather than calming themselves. Self-calming should be introduced in two ways: through environmental modifications and through objects, interactions, and play that support self-calming. However, it is important to determine the best ways for a given child to soothe himself. For example, some children quieten when looking or listening to something novel. Others respond better when helped to organize their own movements.

Oftentimes the parents need to begin by providing sensory inhibition through firm deep-pressure and linear movement. For instance, bringing the hands to midline, touching the palms to body parts, or helping the child to suck on his own fingers are simple ways to accomplished this. Once an infant develops self-calming behaviors, the infant should be helped to use these on his own rather than constantly being organized and calmed by others. With older children, the child may learn a variety of “heavy work” activities like pushing a chair or heavy box across the room. It is useful to combine a calming activity with one that is purposeful. The child may also respond well to a collection of fidgets in a “sensory box” (i.e., squeeze toys, putty, chewing fidget, and so on).

Finally, the child should learn to find ways to soothe in multiple settings. This may be done by structuring the environment to provide a feeling of containment and enacting soothing activities at certain times of the day (see Skill Sheet #1: Self soothing). Using the Symptom Checklist from Chapter 1, one may glean which types of soothing activities are right for the child. For example, the child may self-calm with intense movement, noise reduction, dimming of lights, and firm pressure to the abdomen and hands. The child may take 3–10 minute movement breaks during the school day, doing certain yoga exercises in a dimly lit room with the door closed. While sitting at his desk, he may place a heavy weighted blanket or other weighted toy on his lap and wear noise-cancelling headphones. While listening to the teacher, he might squeeze a stress ball or resistive putty.

The parent may carry a keychain with a picture of them and their child on it or use a blanket, stuffed animal, or other symbol representing the connection between parent and child. When making transitions, the parent can signal the child, “Don’t forget your stuffed animal.” Giving the child advance warning that a transition is about to occur is often helpful. The parent should help the child finish what they were doing, then give them an object to hold that represents the next activity. For example, the parent may say, “We’re leaving for the store. Can you bring along your shopping list too?” and give the child a pad of paper and crayons to scribble on while riding in the car. Some children respond well to photographs or picture cards that show the child doing the next activity. The parents will need to take photos of the child doing different activities, such as riding in the car, swinging on a swing at the park, getting dressed, etc. to implement this method.

Parents should pick a few key behaviors that will be the ones they wish to work on with their child. For example, sitting at the table for eating, turning off the TV when it’s time to go to school, and getting dressed for bedtime may be the three targeted behaviors. Although it is difficult to do, other behaviors that don’t fall into the targeted behaviors should be deemphasized. For example, if the child chooses to dress themselves in odd clothing and it is not one of the top three or four target behaviors, the parents should leave it alone, letting the child do it their way. Compliance and good behavior should be reinforced with praise. Some families like using praise coupled with tangible reinforcers, such as stickers, checks on a chart, a cookie, or a visit to the “Mommy Treat Bag” at the end of the day.

Teaching the child how to problem-solve is very useful in helping them to arrive at strategies for limit setting on their own behavior. The first instinct for the irritable child is to explode or react without thinking. There is a detachment between the thinking mind and the emotional mind. What we are seeking is for the two to merge into a wise mind, as described in dialectical behavioral therapy (Linehan, 1993). In the small child, he learns how to stop himself and internalize limits from the parent who firmly says “no” coupled with a gesture. Similarly, the child needs to identify what behaviors are not OK to continue doing, to visualize something that denotes a visual gesture to stop (i.e., a stop sign, road block, red light), and perhaps even a tactile cue that signals him (i.e., squeezing arm firmly or a firm touch on the leg coupled with saying “stop” in the mind). If the child can’t stop yelling or whatever negative behavior it is, they need to remove themselves from the situation immediately. It is useful for the child to verbally acknowledge their anger and frustration and seek validation from others. This can be very powerful in quieting the irritability. The child needs to feel that others understand their point of view, even if it is distorted or inappropriate for that situation. For example, the child may say, “It is really irritating to me every time I eat with you and you eat food loudly and spill food all over the place. If you don’t mind, I will eat in the kitchen so that I don’t upset either you or me. I hope you can understand that this is something that sets me off.” See Skill Sheets #9: Giving and receiving validation; #14: Observing your own limits; and #20: Communicating effectively with others.

The child needs to understand when their behavior is out-of-control and what limits they will need to impose on themselves. It is helpful to think about how different situations might play out—becoming rageful at kids on the playground when they don’t do what you want, when the family is in a hurry, or the child is in the middle of a video game and has to shut it off, etc. and how they will handle their irritability at home and in public situations. The child and suitable family members (i.e., parents, siblings) should come up with a consistent way of handling the irritability and enforce it. For example, if large family gatherings are apt to set the child off, it is a good idea to keep visits short and successful rather than resulting in an angry outburst.

The child should pick a few key behaviors that will work on. List behaviors that are apt to be problematic and prioritize which ones should be tackled first. For example, sitting at the family dinner table and not arguing, turning off the TV to create less stimulation at nighttime, and getting enough sleep and getting up on time to avoid being rushed may be the three targeted behaviors. Although it is difficult to do, other behaviors that don’t fall into the targeted behaviors should be deemphasized at first until the first three are mastered. It often helps motivate the child to have some form of self-reward if they can consistently accomplish these changes over the course of a month. For example, the child may reward themselves with a meal at a nice restaurant, going to a sporting event, or buying some new music (see Skill Sheets #13: Increasing personal effectiveness and #19: Installing structure and organization in your life).

Whenever the parent is involved in a task, such as cooking a meal, it is wise to offer the child some pots and pans, plastic containers, and small objects to use in filling, dumping, stirring, etc. so that the child can play and imitate them while the parent cooks. If the child complains, the parent should try to redirect him physically or verbally. The parent should be clear to their child about when it is time to pick them up and when it isn’t because their hands are tied up. As soon as mom or dad are finished with their chore, they should reward their child by sitting with them to read a story or playing with them briefly to reward their playing alone. For young babies, they may be carried about in a sling or backpack while the parent does household chores so that he or she can see what mom or dad is doing.

With preschool and school-aged children, it is helpful to teach the child to label their emotions and to read bodily signals so that they can implement calm-down strategies on their own. Sometimes children respond to ideas like a traffic light or mood meter. Red colors denote either time to put on the brakes or mad or angry feelings. Green or blue colors may be used for calm and focused states. Other children respond well to thinking about how their engine is running. A good resource book for therapists is the program developed by Williams and Shellenberger (1994) on “How does your engine run?”

Developing a sense of mastery is important for the child who is irritable to feel that they can overcome frustrations and gain pleasure from their own accomplishments. This can be done by giving the child small “jobs,” such as turning the lights on and off when leaving or entering the room, closing the dishwasher, or pushing a drawer shut. If these things are done everyday, it will help the child feel that he contributes to the family and is a big help. The child should also be encouraged to do age-appropriate activities that he can master, such as stirring with a spoon to make pudding, or pull-apart toys like pop beads.

Often children who are irritable expect others to fix the situation rather than self-calming themselves and coping with the situation in adaptable ways. Self-calming should be introduced in two ways: through environmental modifications and through objects and interactions that support self-calming. However, it is important to determine the best ways for a given child to soothe himself. For example, some people quieten when looking or listening to something novel (i.e., listening to music or book on tape). Others respond better through the sensory channels of movement or touch (i.e., sitting in a vibrating massage chair or sitting in a rocking chair). Some children organize by doing “heavy work” activities, such as moving furniture or lifting weighted toys. It is useful to combine a calming activity with something purposeful (see Skill Sheet #1: Self-soothing).

In therapy sessions, the child may be directed toward recognizing the physiological underpinnings of their irritability. These precursors might be noticing heart rate and breathing patterns which tend to become rapid and irregular when angry or irritable. The person may experience a jittery, nervous edge in their hands, body, and feet. Other signs may be hypervigilance, inability to sustain eye contact, and projecting a scowl or irritated facial expression. These will impact interactions and cause the child to receive social feedback that they are unpleasant to be around. Once the child is self-aware of these bodily signals, the therapist can guide the child in learning deep breathing exercises, stilling the mind, calming the body, and focusing vision on a steady object or person to change the irritability within the body and mind.

Another powerful technique is for the child to learn how to project a half-smile facial expression. This serves the purpose of changing both internal and external feedback that the person receives. The half-smile provides direct feedback to the limbic system and hypothalamus that a positive emotion is being experienced, even if the presiding emotion is irritability. In essence it tricks the brain and helps redirect the emotional valence of the mind from irritability to a more positive emotion. Not only that, the social feedback that a half-smile generates from others versus a scowl helps the child to receive better social reinforcement

Being mindful of how one is controlling and rigid in everyday life is helpful, then to think through what changes one needs to make so that they are an easier person to live with. For example, the child may need to do certain chores at specified times and days to contribute to the family life (i.e., walking the dog, empty recycle and trash). If this works for them and their family, there is no need to change. However, they may be rigid about certain rules or activities that negatively affect the whole family. Select one or two that upset others in the family and find a better way to manage it, allowing breathing room for everyone in the family. For example, if the child insists that everyone in the family do certain activities in a specified order and in a certain place in the house, this should be opened up for discussion with some way to allow for change (see Skill Sheets #12: Changing how you think and #15: Taking control of your own behavior).

It may be helpful for the child to have another person validate their frustration by acknowledging their distress, yet not solving it for them. Getting help at difficult points in the task may be essential for some problem situations. For example, the child may have a physical limitation and cannot write their homework without having mom scribe for them. Positive self-talk is very helpful to persistence. The child should try different mantras, such as “I can do it if I keep trying.” Working for short increments of time (i.e., until a timer goes off) is also helpful in working through the threshold of frustration (see Skill Sheet #6: Positive self-talk).

Developing a sense of mastery is important for the child who is irritable to feel that they can overcome frustrations and gain pleasure from their own accomplishments. Feeling pleasure or excitement will motivate a child’s activity, therefore, it is important to find things that the child wants to learn that can help mediate sustained attention and focus during potentially frustrating activities (see Skill Sheet #11: Creating positive life experiences).

There are several important strategies to help the child with social interactions. Practicing how to listen to others, to take in others’ point of view without disagreeing, and to wait in conversations rather than interrupting impulsively are important skills. Often the child needs something to do to help them remain patient while listening, especially if they are feeling agitated or flooded with emotions during the interaction. Deep breathing and practicing the half-smile can be very useful to this process. The child may benefit from giving themselves a break before they explode at the other person (e.g., leave the room to step outside and calm oneself). It is also very helpful to keep social interactions short until the child learns how to interact in positive ways without erupting or becoming negative and irritable (see Skill Sheets #10: Finding pleasure and making connections; #16: Keeping track of positive behaviors; and #20: Communicating effectively with others).

Increasing one’s self-awareness that their irritability is contagious and creates a negative interaction cycle with others is a major task for the moody person. They may need to restrict what topics they speak to others about, sticking with noninflammatory topics, funny stories, or playful games. This will require the child to let go of things that they may feel passionate about that agitate themselves and others, for example, some children are fixated on certain topics, such as curse words or provocative subjects that might combust the conversational exchange.

Skill sheets are provided, in the appendix, that may be used in treatment to help the child with self-soothing, self-distractions, validation, problem solving, and stilling the mind and body.

It is often useful to help the parents become more attuned to their own reactions to their child’s irritability. For example, if the child is anxious or angry, some parents may resonate to the child’s emotion, becoming almost contagious to the same emotion. Instead of organizing or calming the child, the parents’ reactions may cause emotions to escalate. As a result, sometimes irritable children end up having irritable parents and the irritable mood pervades the household.

Despite Ceci’s tiny size, she was ferocious when she kicked or hit her parents. Mom’s shins were constantly bruised from these assaults. Ceci also had the instinct to throw everything from remote controls to food that she didn’t want to eat. If mom or dad tried to contain Ceci’s physical outbursts or throwing behavior, she would scream, “You hit me!! Stop pushing me!” The rages were unpredictable and could occur over the slightest change in routine. Once upset, Ceci often did things like dig her fingernails into herself or bang her head hard against the wall exclaiming “I hate myself. I wish I were dead.” She sometimes would find sharp objects like a safety pin to push into her arm. Threats to self-harm always brought attention and concern from her parents who constantly worried that Ceci would become a cutter one day. Sometimes Ceci ramped up the self-harm to taking out a screen window in her second story bedroom and attempting to jump out. Once upset, Ceci would follow her parents around, wanting them to witness her distress. She would walk around the house knocking into furniture and lamps, thrashing wildly. When these incidents occurred, her father would take her for a car ride with the windows open, the cool air and change of scenery usually working to calm Ceci down.

Nothing seemed to be fun for Ceci, but she loved her pet cats and guinea pigs, and enjoyed drawing and playing school or grocery store. On play dates, she liked building forts and playing hide and seek.

A week didn’t go by without a major event happening. Due to Ceci’s jealousy about her younger sister, she would often do terrible things to Ellen while she slept. One night she snuck into her sister’s room and poured baby powder all over Ellen’s face, taped her eyelids shut with duct tape, and doused her comforter with catsup. Ellen woke up screaming from the burning on her face and eyes. On other occasions Ceci would booby trap Ellen’s bedroom door, putting a cup of pee on the top of the door that would spill on Ellen as she opened the door. On another occasion she poured toilet bowl cleaner on Ellen’s pillow. Ellen was a major trigger for Ceci. Ceci tried to ruin Ellen’s homework by pouring water all over it, or taking a gift that Ellen received on her birthday and smashing the picture frame and glass. In the same week, she threw a booster seat at Ellen’s face and cut her eye so badly that they had to go to the emergency room. Ellen lived in constant fear of her sister and felt abused by her. Her younger sister often flinched when Ceci walked into the room and sometimes hid behind a book shelf to avoid getting hit or punched by Ceci.

Sometimes these acts of aggression were directed toward her parents. She was known to take dog’s poop and put it on her parent’s bedsheets. It was a common occurrence that Ceci would fall apart on car rides to and from school or after-school activities. Things in the back seat became flying missiles projected at mom’s head. If mom told her to stop, she would grab mom’s hair and pull it as hard as she could while mom was driving, or Ceci would kick wildly on the seat back behind her mother’s seat. The whole time these tantrums were occurring, Ceci would scream things like, “You don’t love me! You wish I were dead!” When her parents might restrain her to prevent her from harming herself or others, it only reinforced Ceci’s view that she was unloved.

Due to Ceci’s strong urge to discharge tension through movement and pounding her body against people and things, we put together a calm-down box. Inside were things, such as wood hammers to pound soft clay into shapes, bubble wrap to squeeze in her hands or to stomp on with her feet, and newspapers to rip up. Ceci loved an inflatable Bop Man that she could kick and punch around in her bedroom. Jumping on a trampoline in the backyard was also an effective outlet. We made an Angry Box for all the members of the family to write down things that made them upset or angry. Ceci loved the idea that others could also be angry besides herself. She was wonderful at coming up with suggestions for others, and frequently wrote in things that bothered her to get advice. This worked better in my therapy room where it was anonymous and she could read about other kids’ problems.

Maintaining routines and sequences in everyday life was very important to Ceci’s mood regulation. We made charts with sequences from getting dressed in the morning all the way through bedtime. She could win a prize for getting enough checks in the day and if she didn’t win the minimum, the consequence was to lose electronics or screen time. Ceci craved having time with her parents to do art projects or to go to the park. She wanted “I love you” moments and time that they played with her. This was very important to improving Ceci’s behavior. We also had to equalize the Ellen–Ceci tension. We set up a system of fairness so that even days, Ceci went first on things; odd days Ellen went first. We also did several sibling sessions in therapy so that the two girls could learn how to play well together and start to enjoy one another’s company.

Another effective treatment for Ceci was to learn to signal her parents that she had “Tornedo Feelings.” This meant to not touch her or hold her down, but to either completely ignore her screaming, and if she was unsafe, to take a large pillow, give her a big hug and help her to calm down. She was allowed to throw beanbags in her bedroom if she was angry. After she calmed down, she then wanted her parents to talk to her about what made her mad and what she could do next time that type of incident came up. We redecorated a part of her bedroom to be a calm-down space where she could write down her “Tornedo Feelings.” We also developed a warning system that her parents could use with her. When she was in Yellow Alert, a problem was cooking up and Ceci was urged to tell her parents what she was feeling and to try to solve the problem with their help. If she was able to turn around a Yellow Alert feeling to the Green Calm Zone, then Ceci received a star on her chart. If, however, her mood entered the Red Alert zone and Ceci lost control, hurt people, or wouldn’t go to her room alone or with the help of a pillow hug to guide her there, then she got two strikes and lost all screen time.

During these episodes of Tornedo moments, Ceci believed that she was the “devil child.” We talked about how everybody gets mad. She was prompted to think “I had a burst through moment. I am lovable and I can be in control. My family will help me.” What also seemed to anchor Ceci was when her mother gave her a quartz crystal to carry with her, when she was at school, home, or with friends, that she believed had positive healing powers for fear, sad, or negative feelings. Every morning she and her mother would say a blessing for the day focusing on positive feelings. This provided Ceci with a mantra that she could hold onto and chant in her mind when she felt that her feelings were sliding south.

In addition to these various strategies, we also had to address Ceci’s anger at the fact that she was such a small child and that people thought her sister, Ellen, was older than her. Ceci expressed how she felt minimized by others and tossed around when kids would pick her up on the playground. She wanted people to think about what she knew and could do and not focus on her size. Practicing a script of how to talk to friends and family who talked about her smallness helped Ceci to take control. One of these scripts was “I know I am small for my age, but guess what I learned to do? I rode a horse the other day and I’m learning to knit.” We also practiced Confident Walking (i.e., runway walk with dress-ups, and so on) so that she looked like she was in-charge of her body. Practicing yoga and deep breathing accompanied by ammunition of what to say when people focused on her size helped Ceci to be less concerned about her size.

Ceci had made great strides in her therapy as a result of this integrated treatment program. She had also received medication for anxiety that had quieted her explosiveness. Although she continued to need support for her mood regulation at age 10, she viewed therapy as a wonderful place to solve problems and to feel supported and cared for.

As an only child, Laila always needed the companionship of one of her parents. She got bored easily and wanted her parents to play games with her, watch movies with her, or take her places. When she did her homework or piano practice, she insisted on her parents being in the room with her. Her parents tried creating a calm-down space for Laila, but she wouldn’t go there on her own to calm down and ended up escalating her screaming to the point that she hyperventilated.

Over the 3 years of my work with Laila, I was struck by her intense need for loving attention. In our sessions, she would gaze at me with an intense look of love and caring. I used this connection with her to validate her distress, but to help her understand her ruptures in mood and to figure out what she could do to help herself. It seemed that even when Laila had a perfect day of relaxation, she still got overwhelmed easily. What set her off was the slightest denial of what she wanted. Small arguments began when she felt that her parents promised her something, then said no, or if they wanted her to do something for the family like fold the laundry and she was not in the mood. A typical kind of argument might start over Laila feeling that she had nothing to wear for the choral concert, then she would find her white shirt and black skirt dirty in the hamper because she hadn’t planned ahead. Occasionally the fights between Laila and her mother could be over Laila choosing to wear something that mom didn’t approve of. Mom’s tendency to be blunt and too honest toward Laila would completely trigger her. For instance, one time Laila was wearing a skirt that rode high on her waist. Mom said that she should pull it down onto her hips and untuck the blouse because it made Laila “look fat.”

Laila thought about how she would like to go in a time machine and change the past. She regretted her behavior and wished that she was different, but she was constantly on the verge of a burst. She felt enormous shame about her mood, but also felt that nobody understood her and that she was alone with this internal state of distress. Part of the problem, too, was that Laila had no best friend and usually alienated her friends by her reactivity and by making highly judgmental comments. For instance, a girl came to school one day with tissue paper stuck in her bra to augment her breasts. Laila confronted her and said, “I know what you’re doing! You’re not fooling us.” She would frequently roll her eyes or get huffy when anybody at school annoyed her, including her teachers.

As we look more closely at the emotional underpinnings of Laila’s mood dysregulation, there are several things that seem to load the deck. She had an intense need to be soothed and loved by others. For instance, she couldn’t go to sleep unless she hugged her parents and was reassured. There were times that she expressed to me worries that her parents would die and she would be left alone. She quickly went to worries about being abandoned. On the flip side, her parents felt that she was suffocating to be with, never-ending with her neediness. She became intensely overfocused on something that she wanted for herself like getting a particular shampoo at the store, then couldn’t let it go, harping on it until her parents gave in or took away her privileges. She also did not seem to have any understanding of how her tantrums impacted others. When her mother said that she had had enough and put in earplugs to muffle out her screaming, or went into her bedroom to get away from Laila, Laila interpreted it as complete rejection. Laila always needed to have the last word on everything. She often pried into her parents’ personal lives to find out secrets. Sometimes she went through their bureau drawers to find whatever she thought they could be hiding. Mrs. D. felt that she had no privacy whatsoever from her daughter, feeling constantly intruded upon.

As Laila entered the teen years, problems arose with phone and internet usage. On a few occasions, Laila would post derogatory remarks about another girl, hoping that she would leave the school because Laila disliked her so much. Once she posted a photo of her breasts that was circulated around the school and resulted in the police coming to school to confront her. She sometimes signed up for apps that were for 18 years and older, then would lose her phone privileges for several months. Her parents put parental controls on all her devices and felt that they had to constantly monitor her.

Proper diagnosis was important to Laila’s treatment plan so that we could assess if she needed medication to help stabilize her mood. Through systematic observations and comprehensive evaluation of mood, we determined that Laila was suffering from bipolar mood disorder. She was helped by medication, but with the unfortunate side effect of weight gain. She also had weekly therapy in addition to participating in group psychotherapy to gain feedback from peers about her behavior.

What has worked for Laila? Because of her high need for validation and connection with others, it was very important that the therapy have this as a foundation. Fortunately Laila felt very nurtured and cared for by me and was open to talking about her mood ruptures without feeling ashamed. She loved to write poetry and stories about her moods and drew beautiful pictures that depicted how she felt. This expressive mode was very useful as a medium between therapy sessions. To help Laila handle her internal state of distress, we constructed two plans—one for home and the other for school. Finding healthy escapes to calm down that she could absorb and make use of was very important. At home her safe place was her bedroom where she would go and hug her stuffed animals, listen to music, or look at one of the meditation apps on her phone, such as Head Space or Soul Buddy. I encouraged Laila to write down what was upsetting to her to share with me in the next session. Sometimes she would call me in an agitated moment and just talking with her for a few minutes helped to deescalate the terrible mood.

Out of the home, Laila was coached to move away from the conflict at hand, to step out in the hallway, or go to the bathroom and take deep breaths, chant a mantra in her head, distract herself with calming thoughts, and think through what would be a good resolution before returning to the situation. I encouraged Laila to quiet the part of the brain that was “on fire” and to not let her feelings take over. It helped her to think about how the planning and thinking part of her brain had gone “off-line” and that she was allowing her emotional brain to take over. I emphasized that she needed to build a highway between the planning center of her brain and her mood center, to take charge of her feelings and quiet the terrible mood to a calm place. Unsticking her negative thoughts was also important. If she was stuck on a negative cycle, I practiced with Laila how to switch topics to something less volatile, then return later in the conversation on what agitated her so. Usually this channel switch helped her to unstick the negative thinking. Laila was also very responsive to body techniques to organize her body and release anger. She liked pounding a pillow or squeezing bubble wrap when enraged. Two good outlets for Laila were marching up and down the steps while pounding her feet or playing a loud, percussive piece on the piano. I also taught Laila yoga and tai chi movements that facilitated movement with breath control. If she could breathe deeply and move while focusing her mind and vision on a beautiful object, she felt much better.

It was very important to teach both Laila and her parents various dialectical behavioral techniques to help them communicate better with one another, to tolerate the distress state that they all felt, and to do calming activities together as a family like something as simple as enjoying a cup of tea together. Equally important was the need to shore up the attachment between Laila and her parents through mutually satisfying activities that gave them pleasure. It was important that they begin to enjoy one another again. The most successful activities tended to be ones outside of the house like going shopping or to interesting places, but I encouraged them to make mealtimes special when they could talk about their days and topics that were fun or compelling. I also encouraged them to spend time together just being in a calm space without arguing (i.e., reading together with music playing in the background, watching a movie together).